What is a pre-existing condition?

Answer: A pre-existing condition is a medical condition or disease that was present
for a specified period, up to two years, before a health insurance policy was
issued.

If you are eligible for group health insurance, federal law limits how an
insurer can define a pre-existing condition and how long treatment for the
pre-existing can be excluded from coverage. Under the federal Health Insurance
Portability and Accountability Act (HIPAA), a pre-existing condition is defined
as a condition for which you received medical advice, care, treatment or a
diagnosis within the six months prior to enrolling in a health insurance group
plan.

For those who do have a pre-existing
condition, HIPAA allows a temporary health insurance exclusion for
treatment. In most cases, your insurance company can exclude medical coverage
of your pre-existing condition for 12 months (up to 18 months for late
enrollees). During that time, the health insurance company pays benefits for
other medical care and treatments, just not those related to the excluded
condition.

If you have a pre-existing condition, it may be important to maintain
medical insurance coverage. This is because those who have a history of health
insurance coverage can reduce the pre-existing condition exclusion period by
providing proof of "creditable coverage."

Individual policy rules differ

However, HIPAA does not provide the same protection to those enrolled in individual
health plans. Health insurance for self-employed or other non-group policies
may permanently deny medical coverage for a pre-existing condition. In
addition, if you have no prior history of health insurance, a company may
decline to insure you.

Private insurers argue that denying coverage to those with a pre-existing
condition is necessary to keep affordable family health insurance available to
others. However, the federal government is taking steps to stop the practice.
The recently passed health care reform changes how insurance companies address
pre-existing conditions.

Starting in 2010, children can no longer be denied medical insurance or
benefits because of a pre-existing condition. In 2014, this protection will be
extended to all U.S. residents. In the meantime, states are in the process of
creating high-risk pools to provide temporary health insurance for those with
pre-existing conditions.